ERIC EJ696129: Extended Diaper Wearing: Effects on Continence in and out of the Diaper

JOURNAL OF APPLIED BEHAVIOR ANALYSIS

2004 , 37 , 97-100

NUMBER 1 (spring 2004 )

EXTENDED DIAPER WEARING: EEEECTS ON
CONTINENCE IN AND OUT OE THE DIAPER

Rachel S. F. Tarbox, W. Larry Williams, and Patrick C. Friman

UNIVERSITY OF NEVADA, RENO

Diaper use is widespread and possibly even increasing across diverse populations in the
United States, ranging from infants to very old adults. We found no reports of an ex-
perimental analysis of the effect of wearing diapers on the frequency of urinary accidents
and the attainment of continence skills (e.g., urinating in the toilet). In this study, we
used a withdrawal design to evaluate the effect of wearing diapers on daily urinary ac-
cidents and successful voids for an adult who had been diagnosed with mental retardation.
Results indicated that wearing diapers increased the rate of accidents and decreased the
rate of successful voids. Clinical implications of these results are discussed.

DESCRIPTORS: caregiver training, incontinence, toilet training

Urinary incontinence causes an array of
problems ranging from personal embarrass-
ment to imperiled public health. As just one
example, incontinence at day-care centers
can promote the spread of infectious diseases
(Berk & Friman, 1990). Yet, abundant ex-
perimental evidence indicates that with skills
training urinary continence can be estab-
lished and maintained effectively in diverse
populations, including infants (Smeets, Lan-
cioni, Paul, & Oliva, 1985), emotionally dis-
turbed adolescents (e.g., Friman & Vollmer,
1995), severely handicapped individuals
(Azrin & Foxx, 1971), and very old adults
(Burgio et ah, 1990). A popular cultural and
commercial trend toward increased diaper
usage, however, appears to promote conve-
nience over continence by forestalling (e.g.,
in the young) or even forgoing (e.g., in the
handicapped or very old) skills training (e.g.,
Goode, 1999; Lancaster, 1990). The con-
venience for caregivers created through use
of diapers with those in care is an indisput-

We thank Deborah Grinager for her assistance with
the preparation of this article and Jay Summers and
the staff at the Prevocational Assessment, Training and
Habilitation Center at the University of Nevada,
Reno, for their assistance with data collection.

Address correspondence to Larry Williams, Psy-
chology Department/296, University of Nevada,
Reno, Reno, Nevada 89557.

able benefit, as are any increases in confi-
dence, mobility, or social participation the
use of diapers may provide for those who
wear them. But whether extended diaper use
produces unwanted behavioral effects has yet
to be experimentally investigated. For ex-
ample, does wearing diapers merely capture
urinary accidents or does it also set the oc-
casion for their occurrence? More important,
does wearing diapers promote or impede the
attainment of out-of-diaper continence
skills? We address these questions in this ex-
perimental case study.

METHOD

Participant. Ralph, a 29-year-old man
with mental retardation, lived in a commu-
nity residential setting for individuals with
developmental disabilities and attended a vo-
cational workshop from 9:30 a.m. to 2:30
p.m. weekdays. Prior to the investigation,
Ralph was regularly placed in diapers (De-
pends® adult diapers) at home by residential
staff and was intermittently placed in diapers
while at the workshop, depending on staff
vigilance and inclination. Ralph arrived at
the workshop in a diaper. This study was
conducted to determine the effects of diaper
use on Ralph’s continence and attainment of
continence skills.

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RACHEL S. F. TARBOX et d.

Procedure. The study was conducted at
Ralph’s workshop. During all conditions,
Ralph was prompted to use the toilet every
half hour. The prompt consisted of telling
Ralph “it’s time to go to the bathroom,” and
gently guiding him to the toilet. Once in the
bathroom, Ralph independently pulled
down his pants and underwear (the staff
took off his diaper when he was wearing
one) and he sat on the toilet. During the
diaper condition, Ralph remained in a dia-
per throughout the day unless an accident
was detected, whereupon the diaper was
changed. During the no-diaper condition,
Ralph’s diaper was removed when he arrived
at the workshop and replaced when he left
for home.

Data collection. Trained staff collected
data at Ralph’s vocational workshop on the
daily occurrence of urinary accidents and
successful voids. An accident was recorded if
Ralph’s garments (i.e., diaper, underpants, or
pants) were seen or felt to be wet in any spot
at the half-hour check. Successful voids were
defined as seeing or hearing urine contacting
the toilet during the scheduled toileting op-
portunities. The time of day that Ralph was
taken to the toilet was also recorded for the
purposes of evaluating treatment integrity.
Treatment integrity data were collected for
100% of sessions. Treatment integrity was
assessed by dividing the number of times
that Ralph was taken to the toilet within 5
min of the scheduled time per day by the
total number of scheduled toilet trips per
day, yielding a mean percentage of integrity
of 92% across all days (range, 72% to
100%). Interobserver agreement was as-
sessed for at least 30% of the toilet trips dur-
ing each day. Agreement was measured by
dividing the number of agreements on each
occurrence of an accident, a successful void,
and the time of day by the total number of
agreements plus disagreements, yielding a
mean percentage of agreement of 100%
across all days.

Experimental design. A withdrawal design
was used to assess the effects of diaper use
on urinary accidents and successful voids.

RESULTS AND DISCUSSION

The results shown in Figure 1 suggest that
wearing a diaper set the occasion for Ralph’s
urinary accidents. In the diaper condition,
Ralph had substantially more accidents (Af
= 1.5 per day) than in the no-diaper con-
dition {M =0.1 per day). The results also
suggest that wearing a diaper had a decre-
mental effect on his using the toilet because,
in the diaper condition, he used the toilet
substantially less often {M = 0.5 per day)
than in the no-diaper condition {M = 1.8
per day). In addition, increased accidents on
the 1st day of the second and third no-dia-
per conditions suggest that when his diaper
was removed, it took Ralph at least a day to
recover his continence.

Although not addressed specifically by
this study, the results suggest that the diaper
exerted discriminative control or was an es-
tablishing operation, or exerted a combina-
tion of these functions. The reinforcers in-
volved cannot be identified with certainty,
but the most plausible candidates appear to
involve negative reinforcement (e.g., decreas-
es in the sensation of wetness, social detec-
tion of accidents, or the effort necessary to
urinate). In addition to the function of the
diaper, it is possible that social reinforcement
played a role in the increase in toilet usage
in the no-diaper condition. Future research
could extend these results by addressing
these issues.

A potential concern involves fluid intake
across conditions. Ralph drank two glasses
of milk a day throughout the study, but no
record of his water intake was kept. Accord-
ing to staff and observers, however, milk
comprised the major portion of his fluid in-
take. A limitation involves the inclusion of

DIAPERS AND URINARY INCONTINENCE

99

Figure 1 . Number of toileting accidents per day are depicted in the top panel. Number of successful voids
per day are depicted in the bottom panel.

only 1 participant, which limits the gener-
ality of the findings.

Concerns, limitations, and unanswered
questions notwithstanding, it seems prudent
to discuss some clinical implications of the
results. Incontinence is a problem across
multiple normal and clinical populations,
and an increasingly popular solution in-
volves the use of a diaper-like undergarment.
In some cases, use of the garments may be
the only feasible solution, but in others,
their use, although convenient for caretakers,
may retard a wearers progress in the attain-
ment of continence skills. Wet diapers often
provide a rationale for their own continued
use (i.e., the fact that they are wet indicates
the need for their use, as was the case in this
study). The results here, however, suggest
that the need for a diaper may be more ac-
curately determined through use of out-of-
diaper tests.

Although the participant in this study was
an adult with developmental disabilities, the
results have implications for other popula-
tions such as normally developing young
children and very old adults. Market forces
are promoting increased diaper use for both
populations, and yet attaining and maintain-
ing full continence is achievable for virtually
all nonhandicapped children and many old-
er, intermittently incontinent adults as well
(Goode, 1999; Lancaster, 1990). The results
here suggest the importance of exploring
whether diaper use instigates accidents or
forestalls appropriate toileting in these pop-
ulations.

REFERENCES

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Burgio, L. D., Engel, B. T., Hawkins, A., McCormick,
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http://www.nytimes.com/library/nationalscience/
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Received December 3, 2002
Final acceptance November 11, 2003
Action Editor, Richard Smith